Developing Leaders in Indigenous health: The Kalaupapa ......Kalaupapa service learning project to...

Volume 1 | Issue 1 | Article 3 – Lee, Harris, Mortensen, & Lee

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Developing Leaders in Indigenous

health: The Kalaupapa service

learning project

Volume 1 | Issue 1

Article 3, August 2016

Winona K. Lee1

The University of Hawaiʻi at Mānoa

John A. Burns School of Medicine

Chessa C. D. Harris



Kawika A. Mortensen



Malia S. Lee



Abstract

The Kalaupapa service learning project engages

indigenous and disadvantaged students in the

cultural, historical, and modern day experiences

of patients with Hansen’s disease (aka leprosy).

The project offers an immersive, culturally-based,

educational curriculum for students pursuing

careers in medicine which culminates with a

huakaʻi (excursion) to the Kalaupapa settlement.

1 Corresponding author: Winona K. Lee, [email protected]

The Kalaupapa service learning project has been

previously shown to enhance students’

knowledge related to humanism in medicine.

This paper explores the potential of the

Kalaupapa service learning project to increase

student knowledge of indigenous perspectives

and potentially contribute to their development

as future leaders in indigenous health. Student

participants completed written reflections that

addressed student perspectives of the experience

and community post-participation. A total of 41

student reflections (from 2008-2013) were

analysed; and emerging themes across reflections

were identified. Results showed that resiliency,

unity, and personal relationships were prominent

themes. For indigenous students, demonstrating

resiliency, fostering personal relationships, and

achieving unity among peers are significant

contributors to student success. In addition, the

experience may have reinforced students’ desire

to serve rural and underserved communities. The

Kalaupapa service learning project is an

educational model that not only enhances future

physicians' knowledge and awareness of

humanism in medicine but also broadens the

participants’ knowledge of indigenous values and

perspectives and has the potential to develop

future leaders in indigenous health.

mailto:[email protected]

Published by Te Rau Matatini, 2016

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Keywords: Service learning, diversity, healthcare

workforce, Native Hawaiian, indigenous.

Acknowledgments. The authors wish to thank

Dr Benjamin Young, founding Director of ‘Imi

Hoʻōla, and Dr Nanette Judd, immediate past

Director of ̒ Imi Hoʻōla for their contributions to

the development of the Kalaupapa service

learning project and this manuscript. The authors

also wish to thank the Queen’s Health Systems

Native Hawaiian Health Initiative for its support

of the ʻImi Hoʻōla Post-Baccalaureate Program.

The views expressed in written materials or

publications do not necessarily reflect the official

policies of The Queen’s Health Systems, and

mentioning trade names, commercial practices,

or the organization does not imply endorsement

by The Queen’s Health Systems.

Ethical approval. Ethical approval was granted

on March 20, 2014 by the University of Hawai’i

(UH) Human Studies Program. The project was

determined to be exempt from federal

regulations pertaining to the protection of human

research participants, regulations code 45CFR

46.101(b) (Exempt Category 4). IRB:

DOC032114-03212014071409.

Background

The Liaison Committee on Medical Education

(LCME), the accreditation body of U.S. medical

schools, requires schools to provide service

learning curricula as part of their physician

training programs. Service learning, grounded in

the pedagogical theories of John Dewey,

emphasises experiential learning outside of the

classroom that is then brought back via student

reflection and application of new insights and

perspectives (Dewey, 1938). Dewey advocates

that educational experiences combined with

community interaction provide the context

necessary to promote knowledge acquisition,

intellectual decision-making, and moral growth

of the learner, ultimately resulting in a sense of

purpose (1938). This unique and intentional

approach further connects students to the

academic topics of the classroom environment

and the experiences of “real-life” which is

mutually beneficial to the student learner and the

community involved (Buckner, Ndjakani, Banks,

& Blumenthal, 2010; Hunt, Bonham, & Jones,

2011; Long et al., 2011). Many medical students

begin their careers with a strong interest in

community health and serving the underserved

(Meili, Fuller, & Lydiate, 2011). Studies show that

students participating in activities focused on

community and the underserved feel more

confident in leading groups toward a common

goal and are better prepared to identify

community needs (Buckner, et al., 2010; Long et

al., 2011). This is of particular interest for

institutions preparing future physicians to

become leaders and advocates for their patients,

families, and communities. Service learning can

integrate the cultural values of a community into

formal instruction, which has been shown to be

effective for developing strong educational

foundations for students with indigenous

backgrounds (Kana'iaupuni, Ledward, & Jensen,

2010).

Efforts to integrate indigenous knowledge into

western educational systems, particularly science

education, demonstrate the potential benefits of

culture-based education (Kana'iaupuni, 2010;

Gibson & Puniwai, 2006; Semken &Freeman,

2008). Culture-based education empowers

students through strengthening cultural identity

and has a positive impact on student outcomes,

including increased self-esteem, self-confidence

and resiliency (Gibson & Puniwai, 2006).

Cultivating these traits is a vital aspect of

developing indigenous leaders who are invested

and connected with their communities. This

paper describes the potential of the Kalaupapa

service learning project to increase student

knowledge of indigenous perspectives and

potentially contribute to their development as

future physicians and leaders in indigenous

health.

ʻImi Hoʻōla Post-Baccalaureate Program

As part of the University of Hawai’i John A.

Burns School of Medicine’s (JABSOM)

longstanding commitment to diversity, the ʻImi

Hoʻōla (Hawaiian meaning “those who seek to

heal”) program is a successful pipeline for

underrepresented and disadvantaged students to

enter into medicine. ‘Imi Hoʻōla’s mission is to

improve health care for Hawaiʻi and the Pacific

by increasing the number of physicians through a

one-year enrichment program. ‘Imi Hoʻōla is a

post-baccalaureate curriculum that accepts up to

12 students from economically, socially, and/or


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educationally disadvantaged backgrounds who

possess the potential to succeed in medicine and

demonstrate a commitment to serve

underrepresented communities in Hawaiʻi and

the Pacific. Upon completion of the program,

students matriculate into the first-year medical

class at JABSOM. ‘Imi Hoʻōla is institutionalised

and is a program located in the Department of

Native Hawaiian Health at JABSOM (Lee, Lee, &

Carpenter, 2014). Since its inception in 1973, 253

‘Imi Hoʻōla alumni have matriculated and

graduated from JABSOM.

History of Kalaupapa

In 1865, the Kingdom of Hawaiʻi passed the Act

to Prevent the Spread of Leprosy which gave police

and district justices the right to arrest anyone

suspected of having leprosy, evaluate their

condition and forcibly relocate them to

Kalaupapa on the island of Molokaʻi. An

estimated 8,000 patients were sent to the

settlement, permanently separating them from

their families and society (Hansen’s disease,

2014). At least 90% of these patients were Native

Hawaiian (Law, 2012). Patients sent to Kalaupapa

dealt with food shortages, lack of medical care

and supplies, inadequate housing, loss of

personal freedom, mandatory relocation of

children, cultural restrictions, and governmental

negligence (Moblo, 1999). These conditions,

combined with lack of a cure, stigmatisation due

to leprosy and complete loss of personal support

systems, made Kalaupapa synonymous with

imprisonment and death. A few dedicated

individuals, such as Father Damien, advocated

for patients’ rights. However, patients were

generally left to fend for their own survival. In

1941, Dr Guy Faget developed a cure for leprosy.

Subsequently, Hawaiʻi’s isolation policy was

lifted in 1969, giving patients the choice to leave

the settlement (Hansen’s disease, 2014).

Although free to leave, decades of mistreatment

and stigma made the patients’ re-entry into

society difficult, and many former patients chose

to remain in Kalaupapa and share their personal

stories from the place that had become their

permanent home.

The Kalaupapa Service Learning Project

The Kalaupapa service learning project formally

began in 2008. However, the idea of connecting

students with this rural, underserved community

of Indigenous patients and residents was initially

conceived by former ʻImi Hoʻōla Director, Dr

Benjamin Young 40 years ago. In 1976, Dr

Young was sailing on the voyaging canoe

Hokuleʻa, as part of the Polynesian Voyaging

Society. On their way back from Tahiti to

Honolulu, the ship anchored at Kalaupapa. It was

during that visit, that Dr Young envisioned the

idea of the first student huakaʻi (fieldtrip) to

Kalaupapa. Dr Young contacted Mr Richard

Marks, a patient with Hanson’s disease, respected

historian, successful businessman and Sheriff. He

along with his wife Gloria hosted students

annually since 1977 until his death in 2008.

During the visits, students would learn about the

community by engaging with patients and

residents in the hospital and community centers.

Students and hosts would also participate in

cultural activities such as fishing and traditional

food preparation. Mrs Marks has continued to

work with the program to identify the community

service needs and learning activities to engage the

students while in Kalaupapa. The Marks family,

as leaders of the community and advocacy group,

Ka ʻOhana O Kalaupapa (the family of Kalaupapa)

emphasise the importance of respecting patients’

experiences and preserving the history of

Kalaupapa. In 2008, the program developed and

implemented the curriculum that is now known

as the Kalaupapa service learning project. Mrs

Marks continues to provide direct input to the

project by identifying the student service

activities based on community needs. Mrs Marks

also coordinates hospital visits with remaining

patients and tours of historical sites. At the end

of the visit in Kalaupapa, students host a luʻau

(traditional Native Hawaiian celebration) for the

Marks family in apprecation of the privilege to

spend time with the Kalaupapa community.

The Kalaupapa service learning project is

integrated into ʻImi Hoʻōla’s Scientific Basis of

Medicine (SBOM) course. The SBOM course is

designed with specific learning objectives that are

focused on helping students gain knowledge and

understanding of health care services from the

perspective of health professionals as well as the

perspectives of the patient, family, and

community. Learning objectives for SBOM are

to: 1) Explain and give examples of varying global

perspectives regarding health and disease; 2)

Describe the need for healthcare services in rural


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and underserved populations; 3) Articulate the

roles of health professionals working in the

health care setting; 4) Predict the epidemiological

and psychosocial impact diseases/health

conditions have on society; and, 5) Recognise and

apply professional behaviours and attitudes as

recommended by the Association of American

Medical Colleges (AAMC). During the spring

semester, Hansen’s disease is discussed utilising

multiple teaching methods, and the history of

Kalaupapa as a settlement for Hansen’s disease

patients in Hawaiʻi is used as a case study to

promote student understanding of how

individuals with widely stigmatised diseases are

impacted through cultural, religious, economic,

and political perspectives. The Kalaupapa service

learning project is considered the capstone of this

learning process, as it culminates with a three-day

immersive experience in Kalaupapa, Molokaʻi.

Continued student learning regarding leprosy and

its impacts is gained through interaction with the

remaining patients at Kalaupapa. The Kalaupapa

service learning project is a highlight of the

SBOM course. Components of the service

learning project are described in Table 1.

Table 1. Kalaupapa Service Learning Project - Components and Activities

Component Activity

Fundraising Students raise a total of $3,000 to be used to support

travel expenses including meals, equipment/tools and

host gifts

Coordination and implementation Students are responsible for purchasing and planning

the service project (i.e. providing meals,

equipment/supplies)

Problem-based learning health care problem Students create learning issues related to Hansen’s

disease that are researched and presented individually to

the class

Individual student research and thesis paper Students conduct research relevant to Hansen’s disease

utilising standard texts and journal articles. Using their

research, students develop a 10 page thesis paper on the

topic

Required reading and written exam on Holy

Man: Father Damien of Molokai by Gavan Daws

Students complete the required reading and take a

written exam to assess their comprehension and critical

analysis of the book

Oral Presentation Students present a 10 minute presentation on their

thesis paper

Service in Kalaupapa Students complete a 3 day project that may include

cleaning yards, painting, or visiting residents. Students

also conduct a luʻau (traditional celebration) and talent

night for the hosts

Tour of Kalaupapa Hosts take students on a tour that highlights

contributions of Saint Damien and historical sites of

Kalaupapa

Reflection Paper Students complete a reflection paper on their service

learning project experience

The Kalaupapa service learning project was

originally conducted to determine whether

service learning enhanced students’ knowledge

and awareness of humanism in medicine and

these results were recently published in BMC

Medical Education (Lee, Harris, Mortensen,


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Long, & Sugimoto-Matsuda, 2016). Humanistic

physicians strive to provide compassionate health

care services that respect the cultural values and

backgrounds of their patients and families (Chou,

Kellom, & Shea, 2014). The authors re-examined

the prominent themes of the project and found

them to be aligned with indigenous perspectives

on health and potentially influential for students

to leadership potential in indigenous health fields.

Methods

As part of the service learning experience,

students were required to electronically submit a

two-page reflection essay about their experience

while at Kalaupapa. Four prompts guided student

responses (see Table 2). These essays were then

filed as part of the each student’s academic

record. Data were extracted from all available

student reflection essays from the classes of

2008-2011. Thus, this study took a

phenomenological approach, which examines the

meaning of events through the lens of the people

closest to the event or situation (Bogdan &

Biklen, 2010). In addition, use of the reflection

essays allowed for inclusion of the students’ exact

words and voices, as opposed to summaries or

second-hand information. Data access and

research procedures were approved by the

Institutional Review Board of the University of

Hawaiʻi at Mānoa. In addition, informed

voluntary consent is obtained at the start of the

ʻImi Hoʻōla academic year for the use of student

likeness, photograph(s), voice, or name for

publication and video purposes. All available

essays from students who participated in classes

of 2008-2013 were included in the analysis. The

demographic profile of the 41 student

participants who completed reflections is

described in Table 3. A total of 41 reflection

essays were thematically analysed by the four

primary individuals on the research team

(O’Connor & Gibson, 2003). Prior to analysis,

essays were de-identified by an unbiased source.

Personal identifiers such as name, date, class, and

instructor were removed from each essay. The

essays were assigned an identification number

and randomly assigned to the group for analysis.

Every essay was read in its entirety by two

members of the research team who

independently identified emerging themes for

each of the four prompts. Allowing codes and

themes to emerge from the reflections supported

the flexibility that is needed in qualitative research

to be grounded in and reflective of the voices of

the participants (Silverman & Marvasti, 2008). In

addition, validity and reliability were ensured

through multiple independent sources evaluating

the same data (O’Connor & Gibson, 2003). Team

members were instructed to review each essay in

four stages: 1) read without highlighting or

marking; 2) highlight key words; 3) assign names

for themes that describe highlighted key words;

and, 4) review themes and expand or consolidate.

All members worked from a common matrix

template to organise their key words and themes

for each of the four prompts. Once all essays

were read and reviewed independently, team

members then came together and compared their

findings. This multi-session process was

facilitated by a fifth member of the research team.

During these group sessions, themes within each

prompt were condensed or expanded, based on

consensus. After the themes were established,

related quotes from the essays that could

exemplify the themes were added.

Table 2. Student Reflection Prompts

Number Prompt

1 Based on what you observed and

experienced during your time in

Kalaupapa, discuss the role of

disease and how it has impacted

the individual, family, community,

and society of Kalaupapa.

2 What did you learn about yourself

through your experience at

Kalaupapa?

3 What did you learn about others?

4 How could a future trip to

Kalaupapa be improved to better

facilitate your learning?

Results

The demographic profile of the participants who

completed post-participation reflections is

summarised in Table 3. Student participants in

the Kalaupapa service learning project are from

disadvantaged backgrounds, many are indigenous

(36%) and the majority of participants originated

from rural communities of Hawaiʻi and the

Pacific (i.e. Guam and American Samoa). Ninety-


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five (95%) of the students included in the study

are of Asian and Pacific Islander descent and

seventy-one (71%) self-identifiy as being raised

with English as a Second Language (ESL).

Each of the four reflection prompts/questions

were designed to support learning objectives

(LO) of the Scientific Basis of Medicine (SBOM)

course.

Table 3. Demographic Profile of Post Participation Student Reflections

Demographic Profile of Post Participation Student

Reflections

(N=41)

Descriptor Frequency Percent

(%)

Gender

Male 19 26.3

Female 22 53.7

Origin

Hawaii 33 80.5

Guam 7 17.1

American Samoan 1 2.4

Origin

Rural 27 65.9

Urban 14 34.1

ESL

No 12 29.3

Yes 29 70.7

Primary Ethnicity

Hawaiian 9 22.0

Filipino 12 29.3

Asian (Chinese,

Japanese, Korean,

Vietnamese) 13 31.7

Chamorro 5 12.2

American Indian 1 2.4

Caucasian 1 2.4

Indigenous

No 26 63.4

Yes 15 36.6

Age Upon Entry (N=41)

Min | Mean | Max 22 | 26 | 34

Question 1. Based on what you observed and

experienced during your time in Kalaupapa,

discuss the role of disease and how it has

impacted the individual, family, community, and

society of Kalaupapa.

Question 1 was intended to illicit responses that

would support LO1): explain and give examples

of varying global perspectives regarding health

and disease; LO2): describe the need for

healthcare services in rural and underserved

populations; and LO4): predict the

epidemiological and psychosocial impact

diseases/health conditions have on society.

Sense of Loss and Resulting Isolation

Student reflections described an immense sense

of loss experienced by patients with Hansen’s

disease due to the forced separation from their

ʻohana (family unit). Adults and children, once

diagnosed with the disease, were forcibly taken

from their families and sent to Kalaupapa,

Molokaʻi. This physical and emotional separation

led to strong feelings of isolation for the patients

sent to Kalaupapa. The isolation experienced by

patients was further impacted by the remote

geographical location of the settlement.

Kalaupapa remains underdeveloped and is

characterised by vast open fields, small houses,

paved roads, cemeteries, and remnants of its

historical sites that symbolise the experiences

endured by the patients of Kalaupapa.

The term ʻisolation’ cannot be truly understood

until one experiences it oneself... Families were

torn apart. Mothers were unable to raise their

children, divorce was sanctioned for those

spouses that had the disease, and patients were

isolated from the larger community. (Student

Reflection #5)

Once an individual was diagnosed with Hansen’s

disease, they were basically marked as a prisoner

and cast away to live in this remote peninsula.

Many of their rights were taken away and they had

no choice but to make this their new home, while

leaving behind loved ones and friends. Many

times, individuals were alone and had to battle

this separation along with their disease. (Student

Reflection #41)

Unity Student reflections also described the unification

of the patients and residents of Kalaupapa. The

creation of strong relationships between

individual patients, among healthcare staff and

patients, and the larger Kalaupapa community

emerged repeatedly in the reflections. Residents

and patients found unity through common health

and social challenges, as well as a unifying sense

of faith and spirituality.

After examining the land and the people of

Kalaupapa, I noticed that it is a very close-knit


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community where everyone is like family…The

community rather than stigmatised the residents,

view these people as their role models…who

despite the sufferings, continued to strive forward

with a positive outlook on life. (Student

Reflection #32)

Resilience The theme of individual resilience, demonstrated

by the residents of Kalaupapa, also emerged in

student reflections. The shared experience of

historical trauma and isolation eventually led to

the creation of lasting relationships between

individuals, families, and communities. The

resilience demonstrated by inflicted patients was

strengthened by the presence of spirituality and

hope.

I sensed that Kalaupapa was an incredibly

peaceful and spiritual place because it was made

up of people who had already had their share of

unrest in the past…Their inspiring spirituality

that spoke of strength in self, forgiveness towards

others, and motivations to keep moving forward

no matter the obstacles that stand in the way.

(Student Reflection #34)

Question 2. What did you learn about yourself

through your experience at Kalaupapa?

Question 2 gives students the opportunity to

reflect on LO5): recognise and apply professional

behaviors and attitudes as recommended by the

AAMC.

Awareness of Self and Others

Students gained self-awareness, recognising their

ability for self-reflection and subsequent personal

and professional growth. They grasped that their

openness to this process of growth was vital to

evaluating one’s own personal strengths and

weaknesses. Understanding the communities’

hardships allowed the students to reflect on their

own strengths and weaknesses, ultimately

enabling them to gain increased empathy toward

others and affirmation of their original altruistic

motives for entering medicine. With increased

self-awareness, students develop a clearer

understanding of their own attitudes and beliefs

which impact how they approach their patients.

Self-awareness is a key initial step to developing

cultural competency and can have a positive

impact on students’ ability to develop effective

working relationships with other professionals

who are a part of the health care team.

Through this experience, I am increasingly proud

and grateful to have been born and raised in the

beautiful and historically rich islands of Hawaiʻi.

I am also proud to be a part of a resilient culture,

Hawaiian, that was able to bounce back from

hardships and discrimination that plagued its

path....this experience also reminds me to be

appreciative of what I have today, never to take

things for granted, and by no means should I be

afraid of hard work to reach my goals in life.


It’s easy to read about these accounts but when

you are watching them tell their stories, with tears

in their eyes, I could not help but feel a degree of

pain they felt. I learned that people with disease

are more than just the disease they have....when I

listened to the residents, I was able to put myself

in their shoes and experience a piece of their

journey. (Student Reflection #4)

Resilience Students expressed that through increased self-

awareness and understanding of relationships

with others, they learned how resilient they were.

Traits that were repeatedly reflected upon

included mental and physical strength,

perseverance and fortitude. “What [the patients

shared] was an inspiration and has motivated me

that there is nothing in life that I cannot

overcome and that as long as I have the will to

move forward, I will have the strength to tackle

it.” (Student Reflection #32)

Reinforced Future Professional Goals Thematic analysis revealed that students

reinforced their perspective of future goals,

reflected on their motives for entering medicine

and affirmed their desire to continue to work

toward reaching those goals. The service learning

project offered students a longitudinal experience

that inspired them to reflect and at times

reinforce their future career aspirations. This

ongoing reflection is an important skill for

students pursuing careers as physicians.

Through my personal experience at Kalaupapa, I

have reaffirmed that I eventually want to serve

rural communities that are in dire need of

physicians. The experience has taught me that my

duty is to those who need me...I have noticed and

appreciate the tight-knit relationship between

patient and doctor, and those are the types of

relationships that I hope to build in the future.



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Question 3. What did you learn about others?

Question 3 helps students apply their perceptions

to concepts associated with LO3): articulate the

roles of health professionals working in the

health care setting; and LO5): recognise and

apply professional behaviors and attitudes as

recommended by the AAMC.

Teamwork

Student reflections described the need to put

forth their best effort and work together to

achieve the goals of the learning service project.

As students experienced success with group tasks

and activities, a greater sense of respect, support,

and trust of their peers developed among them.

Recognising the importance of teamwork enables

students to value the role of peer groups which

can be helpful for studying, completing projects,

and providing mutual support for each other.

Knowing necessity of teamwork offers students

the opportunity to learn about themselves and

how they function as part of a team. This is

significant as students continue their journey

throughout their medical training.

I learned that I am part of a very dynamic and

altruistic group of students. Everyone has

qualities, resources or characteristics that add to

the success of our group as a whole. (Student

Reflection #36)

Fellowship

Student reflections described that the

opportunity to work together outside the normal

academic environment promoted the breakdown

of traditional roles in favor of fellowship among

group participants. Student reflections revealed

that relaxed social environments advanced

bonding and camaraderie among participants.

The luʻau (i.e. traditional Hawaiian gathering) and

participant talent show offered opportunities for

open self-expression and team spirit, fostering a

sense of community among the participants. It is

important for students to develop their ability to

connect with others through fellowship and

social interactions within the professional setting

in order to successfully pursue medicine, which

relies on many individuals coming together to

provide comprehensive services to patients and

their families.

It was also nice to get to know the faculty

members outside of the academic setting. I was

able to realise that they too are very much like us,

each having unique characteristics that I would

have never known about inside the classroom.


Sharing the experiences on the trip brought all of

us closer together, not just as classmates but also

as a family. (Student Reflection #16)

Future Many of the student reflections stated that the

bonds established during their shared experience

at Kalaupapa would continue well past

graduation and into their future careers. Students

felt that they could rely on their classmates for

support and help in both the immediate and

distant future. Participants were also able to

identify how the experience influenced them as

future medical students and physicians since

trusting and relying on their classmates will be an

important part of becoming a part of a

community.

This experience has brought our class closer than

we were before and I will always be grateful for

that. I will take what I have learned to guide me

as I work towards becoming a physician and

when I am a physician. (Student Reflection #26)

Question 4. How could a future trip to

Kalaupapa be improved to better facilitate your

learning?

Although question 4 did elicit student responses

that were concerned with future improvements,

the nature of the responses resonated with LO5):

recognise and apply professional behaviors and

attitudes as recommended by the AAMC.

Length of Stay

The overall consensus of student reflections was

that the time at Kalaupapa should be extended.

During the service learning project, students

became invested in the culture and the people

around them. Regardless of time constraints, it

was also evident in the reflections that the

students’ goals for their careers were reinforced

during their time at the settlement.

An additional suggestion for improvement would

be to extend the length of the trip by at least one

day, so that there would be either time do

additional activities, such as visit the hospital, or

more time for each activity. Although we

managed to accomplish many things during our

short trip, many aspects felt rushed and thus


31

could not be fully appreciated or enjoyed had

there been more time. (Student Reflection #21)

Level of Interaction It was communicated from students that there

was a desire for increased interaction with

patients in the hospital facility at Kalaupapa.

Students expressed a desire to gain an

understanding of rising above diversity through

personal testimonies of the patients. Students

also noted that it would be constructive to have

time set aside to evaluate and share the

information they acquired with others.

Future trips to Kalaupapa could be improved to

better facilitate learning by allowing more

opportunities to interact with residents and hear

their stories. Being able to hear the residents tell

their personal stories and experiences is very

powerful in helping one to understand the impact

of disease. (Student Reflection #21)

The only suggestion I could provide, is to include

a sharing time… the result is the creation of an

even greater bond, and the realisation that there

is always more to learn about a person. (Student

Reflection #5)

Gratitude Respondents expressed gratitude in their

reflections. Students described how thankful and

honoured they were to be afforded this unique

experience. Students shared that lessons gained

while at Kalaupapa can be taken with them

throughout life, and that these lessons will add to

their professional development. Many students

realised how important it is to “hear the patient’s

stories” in order to better address their health

care needs. Students expressed gratitude in being

able to discover the beauty of the land and

learned its important role in the healing of the

indigenous people of Kalaupapa. The gratitude

and reverence for this unique learning experience

demonstrated by the students illustrates the

importance of having students learn directly from

our communities and not just from the

institutions in which they are housed.

It truly was a blessing to be able to go to

Kalaupapa and share this experience with my

classmates and the faculty. Getting to learn and

see the historical places in Kalaupapa was such a

memorable experience…It is also a trip that

reminds us to not take anything for granted and

helping others is a gift in itself. (Student

Reflection #6)

In general, my trip to Kalaupapa genuinely

changed my outlook on life and provided me with

deeper insight into the psychosocial aspects of

medicine. (Student Reflection #3)

Discussion

Resilience Resilience of the patients who were sent to

Kalaupapa, as well as the resilience of the

students in the program, was a prominent theme.

Students appeared to value and relate closely to

this characteristic demonstrated by the patients.

With the loss of identity, separation of family and

destruction of social supports, patients relied on

their individual and collective resilience to

overcome their disheartening circumstances.

Patients also relied on their faith and spirituality

in order to find a compelling reason to rebuild

and create a new sense of themselves and their

community. Through this service learning

experience, students appreciated how Native

Hawaiian patients redefined health and disease

according to their own terms (LOC1), described

how the lack of services, medical and otherwise,

encouraged their own self-reliance (LOC2) and

better understood how the loss of identity, family

relationships, and familiar social supports

impacted society both within and beyond

Kalaupapa (LOC4). Similarly, students reflected

on their own personal resilience. The service

learning project allowed each student to discover

what was needed to create a successful learning

experience but also what they must look to in

order to achieve their professional goals to

become physicians. Similarly to the patients from

Kalaupapa, students overcame personal barriers

to their academic journey, despite past

disappointments, and described finding the

mental and physical strength to persevere

through the challenging one year program. In

order to be academically successful, students

have had to rely on their perseverance, inner

strength, faith, and belief in themselves. In the

competitive field of medicine, resiliency is a vital

factor that contributes to success for students

from underrepresented, indigenous and

underserved populations. For many indigenous

students, they are the first in their families to

pursue the daunting career of medicine and have

had limited role models and resources. Therefore,


32

finding the factors that build and sustain their

personal resiliency is vital to their success.

Unity

An overarching theme of unity was highlighted

by student learners and the patients/residents of

Kalaupapa. Students recognised patients’ need to

regain a sense of family and community in their

collective isolation, and redefine these concepts

in order build a support network (LO1). Their

ability to pull together influenced the availability

of healthcare services at Kalaupapa, and how they

were viewed as a collective by healthcare

professionals (LO4).

Mirroring the patients of Kalaupapa, students

unified through fellowship and teamwork as they

accomplished mutual goals for the Kalaupapa

service learning project. Encouragement of

group work was reinforced by the project’s

student fundraising initiatives and student led

coordination and planning. The overarching

theme of unity among and between the

community and student learners are in alignment

with other service learning experiences in medical

education that promote collaborative

partnerships and community-based approaches

to team-building (Wald et al., 2015). As future

physicians, students must work together with

colleagues as well as other health professionals as

part of a multi-disciplinary team (LO3). Finding

unity within the peer group as well as within the

student’s family support networks are very

important aspects of the indigenous student

experience. Indigenous beliefs encourage the

concept of being connected with others and

unified in harmonious relationships with others.

The concept of unity is a significant source of

support for students and the development of

strong interprofessional skills is critical not only

to the success of the service learning project, but

also to the students’ development as a future

leaders in indigenous health (LO5).

Development of Leaders in Indigenous

Health

The Kalaupapa service learning project immersed

students in the historical and modern day patient

experience of those impacted by Hansen’s

disease and their lives in Kalaupapa. The

combination of academic enhancement through

student research and thesis development, along

with experiential learning in a community-based

setting, created an ideal educational opportunity

for students to learn about and reflect upon

indigenous perspectives and values such as the

importance of relationships, unity and teamwork

as well as resiliency. Following the service

learning project, students expressed respect and

empathy for the patients’ struggles and strengths,

as well as those of their peers. The experience

also reinforced students’ commitment to service,

particularly to populations in rural and

underserved communities. This understanding of

the history and impact of Hansen’s disease on

patients and families helped students develop

empathy and concern for underserved

communities (LO2). Learners also gained a

deeper understanding of the patient experience

and of themselves as future physicians (LO5).

Medical student “wholeness” and engagement

with patients are essential to the training of

caring, compassionate health providers. The

findings of this study demonstrate that a

longitudinal year-long service learning experience

focused on a predominantly indigenous,

underserved and rural community may also be an

effective teaching method to enhance students’

awareness and perspectives of the essential

aspects of indigenous health.

Limitations

Limitations of the study included the number of

student reflections used in the analysis and

limited prompts for the reflection assignment.

There was also a potential bias that existed for the

thematic reviewers, since two of the four

reviewers were instructors of the service learning

project. Because the reflections were graded

assignments, this may also have impacted the

responses provided by the students. The study is

also limited, because there are no data available

regarding the students’ knowledge and attitudes

toward humanism in medicine or indigenous

values/practices prior to the service learning

experience. Student participants in the Kalaupapa

service learning project come from disadvantaged

backgrounds and the majority of the students

originate from rural communities of Hawaiʻi and

the Pacific (i.e. Guam and American Samoa). As

noted previously, ninety-five (95%) of the

students included in the study are of Asian and

Pacific Islander descent and 71% self-identifiy as

being raised with English as a Second Language

(ESL). Although this study may be highly relevant


33

to educational programs that service students

from disadvantaged and underrepresented

backgrounds, these student factors may

introduce potential bias and limit the study’s

transferability to the general post-baccalaureate

and medical student populations.

Future Directions

Given the feedback obtained from the students,

there is consideration to extend the amount of

time spent during the service learning project

while in Kalaupapa. Pre and post surveys of

student knowledge, attitudes, and beliefs

regarding humanism in medicine and indigenous

perspectives toward health would strengthen the

program’s ability to effectively assess the learners’

gains. The instructors would also like to integrate

additional community input to assess learning

objectives and development of the service

learning project over the course of the year. Being

able to have students interact with community

members from Kalaupapa would enrich the

humanistic aspect of the project and offer

additional opportunities for student enrichment

and exploration of the themes that have been

identified by the reflection papers. The program

will explore conducting a follow up survey with

program graduates to assess whether findings of

the study are maintained over time.

Conclusion

In order to meet the unique needs of indigenous

communities, educational programs must

prepare a health care workforce that values and

engages with indigenous perspectives. Through

the Kalaupapa service learning project, students

were able to learn and reflect on the traumatic

history of the mandatory quarantine of Hansen’s

disease patients. From this experience, students

gained a clearer understanding of resiliency of

both the patients and of themselves. By

reinforcing their motivation for medicine and

commitment to service rural populations,

students were able to identify how to be resilient

and flourish in the competitive field of medicine,

where indigenous medical students and role

models remain underrepresented. Students were

also able to recognise the importance of

developing trusting relationships with peers and

finding strength as a unified group which will be

critical as part of their training as members of a

multidisciplinary health care team. For

indigenous students, the importance of an

empathetic and grateful approach to the patients’

life experiences allows them to develop the

cultural competency skills needed to be effective

health care providers and to create the

foundation necessary to maximise their potential

as future leaders in indigenous health.

Abbreviations

LCME: Liaison Committee on Medical

Education

JABSOM: John A. Burns School of Medicine

SBOM: Scientific Basis of Medicine

AAMC: Association of American Medical

Colleges

LO1: Learning objective 1





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Winona Lee is Director, ʻImi Hoʻōla Post-

Baccalaureate Program, Department of Native

Hawaiian Health, The University of Hawaiʻi at

Mānoa - John A. Burns School of Medicine.

[email protected]

Chessa Harris is Instructor, ʻImi Hoʻōla Post-

Baccalaureate Program, Department of Native

Hawaiian Health, The University of Hawaiʻi at

Mānoa - John A. Burns School of Medicine.

[email protected]

Kawika Mortensen is Research Associate,

Native Hawaiian Center of Excellence,

Department of Native Hawaiian Health, The

University of Hawaiʻi at Mānoa - John A. Burns

School of Medicine. [email protected]

Malia Lee is Director, Native Hawaiian Center

of Excellence, Department of Native Hawaiian

Health, The University of Hawaiʻi at Mānoa -

John A. Burns School of Medicine.

[email protected]

Authors’ contributions. WL served as principal

investigator and was responsible for the research

design, data analysis and interpretation, ethics

approval and authorship of the manuscript. CH

contributed to research design, including

questionnaire development, collection, analysis

and interpretation of data and manuscript

revision. KM contributed to research design, data

analysis, interpretation of data and manuscript

revision. ML contributed to interpretation of data


35

and manuscript revision. All authors read and

approved the final manuscript.

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